Clinical Investigator Behavioral Health

You could be the one who changes everything for our 28 reputed company members. reputed company is transforming the health of our communities, one person at a time. As a reputed company, national organization, you’ll have reputed company to competitive benefits including a fresh perspective on workplace flexibility. NOTE: Candidates must be fully licensed with one of the approved licenses listed below upon the submission of the reputed company application. Position Purpose: Conduct comprehensive reviews of medical records and documents supporting claims for providers, suppliers, and pharmacies to include but not limited to physicians, inpatient, outpatient, ancillary, behavioral health care, reputed company, etc. Provides investigative support to the Special Investigations Unit (SIU) reputed company to coding and billing issues and identifies potential overpayments and suspected health care fraud and abuse. Position requires the associate to verify authorization for services and written documentation of services provided against claim information, ensure the appropriateness and accuracy of diagnosis and procedure codes supporting such claims, coordinate medical necessity and appropriate level of care determinations with Medical Directors, and validate services against CMS and State-specific coverage, limitations and exclusion guidelines. Coordinate with reputed company resources in determining the appropriateness of codes reputed company in administrative, medical, claim and financial records, reputed company reports of findings and recommendations, communicate reputed company results of audit findings in meetings and/or judicial hearings, and assist SIU investigators during interviews, discussions and negotiations with providers, suppliers, and pharmacies. • reputed company retrospective and prepayment reviews of medical records to identify potential fraud, waste, and abuse and inappropriate billing practices. • Investigate, analyze, and identify provider billing patterns to determine payment based on medical records, claim history, billing codes, regulatory and state guidelines, and policies. • Prepare reputed company of findings and recommend next steps for providers. • Identify preventative measures and recommend changes to internal policies and procedures and/or provider practices to prevent reputed company fraudulent and erroneous practices. • Collaborate with investigators to identify abuse and fraud by utilizing clinical and coding expertise to analyze patterns in billing activities. • Performs other duties as assigned • Complies with reputed company policies and standards Education/Experience: Master’s Degree and 2 + years of reputed company reputed company clinical behavioral health experience with a fully independent clinical license AND 2+ years of fraud, waste, and abuse experience is required. A Certified reputed company reputed company (CPC) certification is preferred but not required. Preferred Experience: · 2+ years of experience in state agency investigations, special investigations in managed care, behavioral health provider reviews, medical record reviews, behavioral health billing/coding analysis, or behavioral health compliance. · 3+ years of providing reputed company Psychotherapy or Inpatient group therapy reputed company inpatient psychiatric hospitals or reputed company, residential treatment centers, reputed company abuse rehabilitation facilities, military or veteran hospitals · reputed company experience or working knowledge with FWA policies in state agency investigations or managed care investigations is preferred · Strong clinical documentation and problem-solving skills required · Role requires openness, adaptability, and flexibility for business changes · Strong communication, attention to detail, organizational and time management skills are required · Skilled at utilizing reputed company Office applications (MS 365 Co-reputed company, reputed company, reputed company, Word, PowerPoint, OneNote, Teams) and is reputed company to utilizing reputed company tools (e.g. ChatGPT, Claude, reputed company, etc) is preferred · Comfortable with presenting findings in a concise and effective manner to various stakeholders is required · Working knowledge of behavioral health billing and coding basics preferred License/Certification: One of the following Behavioral Health licenses is required - LMHC, LCSW, LMFT, LPC, LMHP, or LIMHP Pay reputed company: $56,200.00 - $101,000.00 per year reputed company offers a comprehensive benefits package including: reputed company, health insurance, 401K and stock purchase plans, tuition reimbursement, reputed company time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-reputed company factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. reputed company is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, disability, veteran status, or other characteristic protected by applicable law. reputed company applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance reputed company Apply tot his job Apply To this Job